Hopkins and colleagues should be commended for their effort in investigating quality of life (QOL) and postoperative pain as primary outcomes of a study comparing VATS with standard thoracotomy in cancer patients. The investigators concluded that the two approaches didn’t differentiate in terms of late QOL and pain related symptoms.

However, the applicability of these results needs to be considered carefully due to some limitations in the patient reported outcomes (PROs) methodology.

PROs have been widely recognized by International Surgical Societies with specific work forces (European Society of Thoracic Surgeons Quality of Life and Patient Safety working Group) and inclusion in Lung Cancer Management Guidelines (ACCP guidelines) (1). However, from a recent survey among general Thoracic Surgeons, we are aware of the lack of routine PROs data collection and of a standardised methodology when the latter is described (2).

Two crucial points when approaching QOL research studies in surgical oncology include: time of administration and choice of questionnaire.

Regarding the first point, we acknowledge the logistic and financial difficulties in the “fast track” surgical era to find the right time for completion of PROs questionnaires as the patients are often overwhelmed by multidisciplinary information about their treatment journey. However, to evaluate the effect of a particular treatment or a surgical approach, it’s always recommended to longitudinally follow the evolution of QOL, at least for the first 12 months after the operation as it slightly recovers after the initial decrease reported in literature (3). Baseline assessments of QOL before surgery are also helpful in interpreting change over time and comparing outcomes in different treatment groups.

This is particularly important when we cannot compare the scores with the general population, like in most of the lung cancer specific questionnaires. As already established in other oncological settings (4), electronic PRO collection is emerging in the Lung Cancer field as Internet use among our patients continues to increase steadily (5). We have initiated the LILAC study (ClinicalTrials.gov Identifier: NCT02882750), a UK-based study which will inform the use of web-based QOL data collection among early stage non-small cell lung cancer patients and comparing these data with those from the stereotactic ablative radiotherapy (SABR) patients.

In relation to the second point, the importance of choosing the right questionnaire is crucial especially for surgery where studies are often limited to cross sectional protocols.

According to the trial’s design, we can opt for a generic or cancer specific tool. The feature of a generic survey is that it can allow for comparison of a patient population with a healthy one. The most commonly used validated questionnaire (SF-36V2) has been widely used in our specialty (6).

Cancer specific questionnaires study the effect of cancer and its treatment on QOL. Many of the lung cancer specific questionnaires have been designed and tested for systemically treated patients, with most of the question items related to the effects of chemotherapy or radiotherapy. However, a work force from the European organisation for research and treatment of cancer (EORTC) is updating the questionnaire on the quality of life of patients with lung cancer (QLQ-LC13), to adapt it to the therapeutic possibilities available today and, above all, to analyse its measurement quality (7).

We congratulate Hopkins and colleagues for stressing the importance of the patients’ voice rather the oncological benefit in evaluating a surgical approach. QOL data is recognized as being even more relevant when considering surgical versus non-surgical therapies for high-risk patients with early-stage lung cancer. For this reason, we advocate a rigorous methodology when designing future trials comparing surgical modalities from the patients’ perspective.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Koller M, Warncke S, Hjermstad MJ, et al. Use of the lung cancer-specific quality of life questionnaire EORTC QLQ-LC13 in clinical trials: A systematic review of the literature 20 years after its development. Cancer 2015;121:4300-23. [Crossref] [PubMed]